Laserfiche WebLink
MARION COUNTY PUBLIC WORKS <br /> do "oliiiii '_ BUILDING INSPECTION DIVISION <br /> i/`� �� 5155 Silverton Rd NE <br /> UM/ <br /> Salem OR 97305 j I D _ <br /> (503) 588-5147 Fax (503) 588-7948w B p�v��1.R t3 <br /> http://ww .co.marion.or.us/PWuildingInspection I (A)U t <br /> sozo-"' t <br /> NOTICE AUTHORIZING REPRESENTATIVE fte-T on{ALk <br /> I, 9a, ,,,,, (ie\ P ci'S ` K Q-Q-t'\ , have authorized <br /> (Property Owner/ Print Name) <br /> R 3 Ro_LA, TO r\ — c-I Q-o-►'\ S I ca.:(Q to act as my agent in performing the <br /> (Authorized Representative/Print Name) <br /> activities necessary to obtain site evaluations, permits, and other onsite wastewater treatment program <br /> services provided by the Department of Environmental Quality or County Agent on the property <br /> described below in accordance with OAR chapter 340, division 071. <br /> PROPERTY IDENTIFICATION: <br /> 1 ( (9 HoRQb ST , G0.iQ5 , 0 R c173LI (p <br /> Property Situs or Street Address <br /> And described in the records of MARION County as: <br /> fon <br /> Legal Description CloAe c l�P, (B' 1 t_ Cj - 1 o) Tax Lot#(s) Q' 3 '1 - t N - 01 3Ot <br /> PROPERTY OWNER:� ` <br /> { <br /> Printed Name: )�C7 QG60. (-r Ac, — li-) 12'0--1nf3o/Signature: . Cr\-cc - Date: 7 of i <br /> Address: 8 p I F Po Q\/ 1 f2,k,J 3 r -1 -5 Phon<5,0 i 0 9 g g 13 <br /> City, State, Zip qy Yr ,Il O I► t ©i, 91 3 (O 0 Fax: <br /> E-mail Address 6 Go_+YI u-c,K 131 G, Cr• ( c , CO r- <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: I to r r 1 &lP IA) O n <br /> Company Name: C_ Le a.n S 1 a.4-e 1 i_ 2 _c, <br /> Signature: Date: V]l _0/.3.1 <br /> Address: /5 5" 5 1A) 1 j,P.r,v la )cl P Lae' e - Phone: 5 fr3-Q ,)- „�5 , <br /> City, State, Zip S}-Q /1-n,,-5 DR g 38 -3 Fax: 5 n 3 - -)6 Q-- 5 Cog <br /> E-mail Address C/ S t 3_ 0 !la,-�c�o , c i._-)m <br /> DEQ License# .9 i q D CCB # �,:a 0 ,a f 4 <br /> G:\FORMS\SEPTIC\S-07 Auth to Apply doc <br /> MCS-07 Rev 03/10 <br /> SEPTIC 4 <br />